Background:
With 1 million new cases in the world each year, breast cancer is the
commonest malignancy in women and comprises 18% of all female cancers.
At present carcinoma breast is the leading cancer in India and is
competing cancer cervix in incidence. Epidemiological studies at
regional and global levels suggest the occurrence of carcinoma breast
at a younger, premenopausal age in Indian and Asian women as compared
with western women. Knowledge of this factor emphasizes the need to
modify the timing of modalities of detection of early carcinoma and its
management. According to literature, majority of carcinoma breast cases
in the western countries present in Stages I and II of the disease
whereas in India majority cases present in Stage III of the disease.
The objective of this study is to observe and study age correlation
with female breast cancer. Methods:
A retrospective study was conducted in 267 patients of
histopathologically confirmed breast cancer. Results: Mean age of
subjects was 44.34±8.55 years. Age distribution showed peaks
at 41-50 years with 134patients.This study shows that 71.90% of the
total patients were having advanced carcinoma breast (Stage III, IV)
and 73.7% of these patients were below 50 years of age. Conclusions: Breast
cancer is increasingly occurring in younger age groups in India when
compared with western countries and a more aggressive nature of the
disease strikes in their reproductive period suggesting the need for
change in modalities of early cancer detection and adjusting preventive
and therapeutic efforts.

The most prevalent cancer in the world is breast cancer (4.4 million
survivors upto 5 years following diagnosis)[1]. It is the most frequent
cancer and cause of cancer deaths in females in developed and
developing countries[1]. Breast cancer accounts for 23% of all newly
occurring cancers in women worldwide and represents 13.7% of all cancer
deaths [1]. Breast cancer remains a leading dreadful cancer of women in
India as well. Breast cancer has ranked number one cancer among Indian
females with age adjusted rate as high as 25.8 per 100,000 women and
mortality 12.7 per 100,000 women[2].Young age has been found as a major
risk factor for breast cancer in Indian women[2].

Epidemiological studies at regional and global levels suggest that this
cancer occurs at a young premenopausal age in Indian and Asian women
compared to western women who get it more than a decade or more later
[3]. Studies suggest that the disease peaks at 40-50 years in Indian
women [1]. The stage of disease at the time of reporting is worse in
younger patients. Literature shows that in India majority of new cases
are advanced stage- locally advanced or higher stage at the time of
diagnosis [4]. According to various studies majority of carcinoma
breast cases in the west report in Stages I and II of disease, whereas
in India 45.7% report in advanced stages[3,5]. Asian countries may
experience a potential breast cancer epidemic over the next decades as
women adopt western lifestyles, marrying, and bearing children later in
life, decreasing parity, shorter duration of breast feeding and change
in dietary habits. Knowledge of all these factors means need to modify
the modalities of detection of early carcinoma and its management so
that the outcome of the disease is not compromised.

Methods

Place of study: Department
of Surgery, GCS Medical College Hospital and Research Centre,
Ahmedabad, Gujarat.
Type of study: Retrospective study
Period of study: From 2011 to 2017.

Sampling Method:
Consecutive. Data were collected from both outpatient department and
inpatient department. Data were collected using detailed proforma. A
total of 267 patients were included in the study and their data
regarding age, stage of disease, medical history, past history and
family history were collected on a predesigned proforma.

Inclusion criteria: All
the histopathologically confirmed female breast cancer cases during the
said period were included.

Exclusion criteria:
Those patients where detailed case reports were not available were
excluded.

Statistical Analysis: All
the relevant collected data was compiled on a master chart first then
organized by scientific calculator and standard appropriate statistical
formula. The results are presented in Tables.

Results

A total of 267 patients were treated for breast cancer in the 7-year
period. Mean age of patients was 44.34±8.55 years. Age
distribution showed peak at 41-50 years. Number of patients below 50
years of age was 161. Out of 267 patients 134 were between 40 and 50
years of age (Table 1). Number of patients in age groups 21-30, 31-40,
41-50, 51-60, >60 were 3, 24, 134, 78 and 28 respectively.
Minimum age was 26 years and the maximum was 82 years and median age
was 46 years.

Table-1: Distribution of
breast cancer by age (n=267)

Age

Number of lesions

t (%)

n=267

0-20 years

--

--

21-30 years

3

1.12

31-40 years

24

8.99

41-50 years

134

50.18

51-60 years

78

29.21

>60 years

28

10.48

Total

267

267(100)

Mean±SD

44.34±8.55

Out of 267 cases evaluated for presence of family history, 32 cases
(11.98%) revealed positive family history of cancer, among which breast
or ovarian cancer were the commonest type (74.0%). Patients below 40
years of age(27 patients) had more frequent occurrence of family
history as compared to above 40 years.

Of the total 267 patients 192 presented with advanced stage (Stages III
and IV) of breast cancer. This study shows that 71.90% of the total
patients were having advanced carcinoma breast (Stage III, IV) at the
time of reporting and 73.7% of these patients were below 50 years of
age (Table 2).

Table-2: Stage of breast
cancer at presentation (n=267)

Stage

Number

Percentage%

Stage I

18

6.74

Stage II

57

21.34

Stage III

130

48.68

Stage IV

62

23.22

Discussion

Breast cancer is the commonest cause of cancer death in women
worldwide. Rates vary about five-fold around the world, but they are
increasing in regions that until recently had low rates of the disease.

Many of the established risk factors are linked to oestrogens. Risk is
increased by early menarche, late menopause, and obesity in
postmenopausal women, and prospective studies have shown that high
concentrations of endogenous oestradiol are associated with an increase
in risk. Childbearing reduces risk, with greater protection for early
first birth and a larger number of births; breastfeeding probably has a
protective effect. Both oral contraceptives and hormonal therapy for
menopause cause a small increase in breast-cancer risk, which appears
to diminish once use stops. Alcohol increases risk, whereas physical
activity is probably protective. Mutations in certain genes greatly
increase breast cancer risk, but these account for a minority of cases.

Age is one of the most important risk factors for breast cancer. It is
a common observation that risk of breast cancer increases with age.
Median age of 46 years in the patients with breast cancer is much lower
than median age seen in American population at 62 years [6].

The mean age of women with breast cancer in present study is 44.34
years, which is similar to study by Saxena et al in India where mean
age is 47.8 years[7]. This mean age is also younger than seen in
research on breast cancer elsewhere in developing countries and a
decade earlier than western women [7,8,9]. A study in India shows that
there are two peaks in the age at diagnosis of breast cancer at 41-50
years and 51-60 years [10]. The latter peak is common with peak in
western countries, but the peak at 41-50 years shows that the disease
occurs at a younger age in Indian patients as compared to the west.
Data of Delhi, India from 2001 to 2003 under national cancer registry
program of ICMR recorded 529, 544, and601 cases of breast cancer in age
groups 40-44, 45-49, and 50-54 years respectively out of a total of
3777 breast cancer cases recorded[11].

In our study total 158/267(59.17%) patients belonged to age group 31-50
years. Similar results are observed in the study by Sandhu et al where
a majority of the patients (65.8%) were in the age group of 31 - 50
years [12].

In our study family history of cancer particularly breast and ovarian
cancer(74%)was found in 32 cases (11.98%) and most of these patients
were below 40 years of age(27/32 patients).Similar results were found
in study by Saxena et al where most of the patients with positive
family history had age less than 45 years[7].

Well-established risk factors for breast carcinoma include age,
ethnicity, family history of breast or ovarian cancer, age of menarche,
age at menopause, age of first full term pregnancy[13]. Despite same
risk factors the western population themselves do not have onset at
younger ages, implying that there may be some genetic impact of Asian
population to develop breast cancer earlier or there might be a role of
environmental factors yet to be explored[14].Therefore westernization
may be responsible for increasing incidence of breast cancer, but may
not be the reason for its occurrence in younger age groups[14].Breast
cancer is a hormone dependent malignancy and the hormonal factors might
be affecting Asian women differently who get menarche and menopause
earlier in an average shorter life span compared with western women.
However, all above factors only explain the increasing incidence of
carcinoma breast but does not explain development of carcinoma in
younger age.

Staging of the disease is essential particularly for estimating
prognosis, planning treatment, interpretation and comparison of
outcome. According to various studies majority of carcinoma breast
cases in the west report in Stages I and II of disease, whereas in
India 45.7% report in advanced stages[3,5].Similar results were
observed in our study where 71.9% patients presented in Stages III and
IV of disease.

Of these advanced cases of present study 73.7% patients were below 50
years of age confirming that the disease is more aggressive in younger
patients. This study highlights the fact that in the population this
malignancy is very aggressive and younger the age of getting this
malignancy more aggressive is the disease. Delayed reporting with
advanced carcinoma may be due to lack of awareness program, economic
factors, social taboo, religious factors and paucity of health and
medical facilities. Screening programs that have been shown to be
successful in Western countries cannot be implemented in a similar way
in the country because the efficacy of mammographic screening might be
questionable in populations with a different epidemiology of breast
cancer regarding age, risk factors, and ethnicity.

Limitation of this study is being limited number of patients studied in
a tertiary level Hospital in Ahmedabad over a very brief period which
may not be representative of whole country though gives an idea
regarding the pattern.

Conclusion

Breast cancer occurrence has undergone an age shift. It presents at
younger ages in Indian population with more advanced stage of cancer at
presentation. A national cancer registry and large-scale population
study may give a robust picture about the age of presentation and the
stage at diagnosis of breast cancer.

Thus this study brings light on the presenting stage of breast cancer
which is advanced even at the comparatively young age. So it is the
need of hour to focus on detecting breast cancer at an early stage as
possible. This important epidemiological issue will influence the
screening programs for breast cancer detection at early stage and alert
women regarding various risk factors.

Author contribution : Both the authors were pioneer in designing the
study and performa. First author collected the data and compiled it. He
also analysed the collected data. The second author with the help of
first author wrote down the entire study. The correspondence was
handled and further corrections were made by the second author.